Despite advances in pain-management education, many nurses aren’t familiar with the multidimensional aspects of pain—highlighted more than a decade ago by the National Institutes of Health and more recently by the American Society for Pain Management Nursing. Pain has seven dimensions, or core aspects: physical, sensory, behavioral, sociocultural, cognitive, affective, and spiritual. To perform a comprehensive pain assessment, you must understand what each dimension encompasses and be able to evaluate all dimensions accurately.
The physical dimension refers to the effects of the patient’s anatomic structure and physiologic function on the overall experience of pain. Anatomic structure and physiologic function can directly influence whether or not a stimulus induces pain, how quickly and in what manner pain is transmitted, how a person consciously perceives pain, and how the body reacts to painful stimuli. Assessing this dimension enables you to identify possible sources of pain and guides selection of an analgesic with an appropriate action and duration.
To assess this dimension, check for current or recent changes in the patient’s musculoskeletal, neurologic, or visceral anatomy by asking about previous surgeries or medical procedures and current or previous traumatic injuries, vascular or pressure ulcers, tumors, or degenerative bone, muscle, or nerve disease. Review the patient’s chart for diagnoses related to a change in physiologic function, such as inflammatory processes, hematologic disorders, chronic neurologic disease, and metabolic diseases (including diabetes). For example, the pain of diabetic polyneuropathy can cause release of chemical mediators that sensitize and reduce the action potential threshold of nociceptive (pain-receptive) fibers, leading to moderate to severe burning or knifelike pain along an identifiable nerve pathway.
The sensory dimension encompasses both the quality and severity of pain. It includes the patient’s report of the location, quality, and intensity of pain. Assessing this dimension helps quantify the pain and clarify the extent of poorly localized or radiating pain. To evaluate it, ask the patient to describe or point to the pain location. Using an open-ended question, ask him or her to describe what the pain feels like. Common descriptors include sharp, dull, aching, throbbing, stabbing, burning, and shooting. These terms can hint at the type of pain—somatic, visceral, or neuropathic. For instance, patients commonly describe visceral pain (pain originating in an organ) as poorly localized, sometimes radiating, and dull.
Finally, ask the patient to quantify the level of pain using a numeric rating scale. But be aware that to use a numeric rating scale (such as a 0-to-10 scale), the patient must be capable of enough abstract thinking to quantify the subjective experience of pain; patients with reduced cognitive capacity, as well as young children, lack this capability. If your patient can’t communicate or otherwise express a numeric score, use a behavioral rating scale to evaluate physical indicators (such as physical activity, positioning, and general appearance) for presence or absence of pain. One such scale is the FLACC scale, in which the nurse scores the patient in each category (Face, Legs, Activity, Cry, and Consolability) from 0 to 2.
The behavioral dimension of pain refers to the patient’s verbal or nonverbal behaviors exhibited in response to pain. To assess it, rely on direct observation and continued patient interaction. Watch for common behaviors associated with pain, such as guarding, splinting, tensing up, crying, moaning, and massaging a specific body part.
A patient’s refusal to take pain medication—or conversely, frequent requests for it—should prompt you to look for underlying causes of these behaviors, and adjust interventions as necessary. Also check for more subtle behaviors, such as forgetfulness, confusion, delirium, insomnia, anxiety, and depression. While these sometimes reflect other medical conditions, they may arise from pain.
If you identify behavioral signs and symptoms of pain, ask if the patient is experiencing pain. This shows the patient you acknowledge the experience of pain and promotes timely intervention.
The sociocultural dimension is the effect of the patient’s social and cultural background on perception of and response to pain. It can influence beliefs about pain medications, treatment options, hospitalization, and the roles and responsibilities of both healthcare providers and the patient. It also may influence pain-management decisions.
Take time to learn about your patient’s sociocultural background. Ask questions about pain-management preferences, previous methods used to manage pain, and use of over-the-counter, holistic, homeopathic, or nonpharmacologic remedies. During the transition from one healthcare setting to another, inform other healthcare providers of these influences to prevent ambiguity, confusion, and delays in treatment.
If the patient doesn’t speak fluent English, family members, such as children or grandchildren, may be able to provide sociocultural information and help communicate the benefits of pain-management options to the patient, thus involving the patient in decision making.
The cognitive dimension refers to thoughts, beliefs, attitudes, intentions, and motivations related to pain and its management. Before assessing this dimension, evaluate the patient’s cognitive capacity and functioning. Review the medical history for diseases or conditions that may impair cognition; if any exists, assess its current level of progression. In some patients, pain can temporarily worsen preexisting cognitive limitations.
The cognitive dimension also may manifest in a patient’s refusal to participate in pain-management planning or treatment. If this occurs, try to understand the rationale behind the decision; some treatment refusals stem from misunderstandings. For instance, a patient might refuse as-needed pain medication in the mistaken belief that opioids cause addiction in most people who use them for pain control.
Social stress, family pressures, and hospitalization also may affect cognitive functioning or self-conceptualization in a patient with pain. The patient may need to make multiple life-altering decisions within a short time; these stressors can be mentally exhausting, causing the patient to relegate pain-management planning to a lower priority than other healthcare decisions or to disengage from decision making.
Finally, assess the patient’s educational and professional background, as these may influence ideas about the causes, treatment, and prognosis of pain.
The affective dimension refers to feelings and sentiments in the presence of pain—how the patient feels emotionally as a result of pain. Start by asking about the patient’s emotional state; pain can be emotionally draining and compromise emotional well-being. Especially if the patient has chronic pain, look for signs and symptoms of depression. Some studies show that most people with chronic pain eventually exhibit classic signs and symptoms of depression: sadness, crying, insomnia, loss of interest in activities, and social withdrawal. Other affective responses may include anger and frustration.
Then assess the patient’s emotional outlook. Ask, “How do you think you’ll feel emotionally if the pain continues?”. Be aware that unresolved negative feelings and maladaptive emotional responses to pain ultimately can lead to more problematic issues, such as anguish and suffering.
The spiritual dimension refers to the ultimate meaning and purpose that the patient attributes to pain, self, others, and the divine. Find out about the patient’s religious or spiritual practices and preferences, which could affect pain-management planning. Based on religious views, some patients may wish to avoid traditional medical approaches to pain management, relying instead on alternative therapies, lifestyle or dietary changes, or other nonpharmacologic approaches.
Elicit the patient’s views on the meaning or significance of self, life, and the presence of pain. Some nurses feel unprepared or ill-trained to do this—but simple, open-ended questions from a caring practitioner can help patients feel more comfortable sharing their motivations for living, surviving, and enduring pain.
Finally, ask the patient about personal relationships; try to gauge whether these are loving, accepting, and supportive. Positive relationships foster a sense of connectedness with others and enhance feelings of tranquility and inner peace despite pain. Another way to assess the spiritual dimension of pain is to review the nursing diagnoses Spiritual distress and Readiness for enhanced spiritual well-being. To help prevent the devastating outcome of spiritual suffering, work with the patient to promote spiritual wellness.
Relieving patient’s pain is a high nursing priority. To promote pain management, take the time to apply your knowledge of the dimensions of pain to your nursing practice.
Cory Silkman is Manager of Patient Care Services in the Department of Rehabilitation at Sinai Hospital of Baltimore in Baltimore, Md.